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Adductor Tendinopathy

From WikiSM

Other Names

  • Adductor Tendinosis
  • Adductor Tendinitis
  • Adductor Tendonitis
  • Adductor paratenonitis
  • Adductor enthesopathy
  • Groin Pain Syndrome

Background

History

  • Unclear when the first adductor tendinopathy case was published in the literature
  • Renstrom discussed chronic tendinitis of the adductor muscles in a 1980 publication[1]
  • Akermark et al may have been the first when they published a cse series in 1992[2]

Epidemiology

  • Most of the epidemiology focuses on "groin injuries" and does not distinguish etiologies, which can be challenging
  • Injuries in the groin area [3]
    • Occur between 2% and 7% in athletes
    • Are as high as 12%–18% in soccer players[4]
    • There is a male predominance

Introduction

Cross section of the thigh with medial muscles in blue[5]
Muscles of the medial compartment of the thigh[6]

General

  • Athletes may have an acute injury or strain that fails to resolve
  • Adductor magnus is most commonly implicated
  • Symptoms are typically insidious with patients reporting gradually worsening pain over time

Etiology

  • Common in sports that involve repeated kicking, rapid change of direction
    • Leads to repetitive microtrauma
  • Overstretching may precipitate pathology
  • Sudden increase in training type or intensity

Anatomy of the Hip Adductors

Anatomy of the Pubic Symphysis

  • Closely associated with the adductor muscle group
  • Nonsynovial, amphiarthrodial joint
  • Attachment site for most of the abdominal musculature
  • Also site of origin for the adductor muscles

Associated Conditions

Risk Factors

Sports

  • Soccer
  • Rugby
  • Australian Rules football
  • Ice Hockey
  • American football
  • Horse riding
  • Gymnastics
  • Swimming

Musculoskeletal

  • Inadequate abdominal strength
  • Lack of flexibility of posterior chain[7]
  • Leg Length Discrepancy
  • Strength imbalance
  • Lumbar hyperlordosis
  • Sacroiliac, sacrolumbar and hip arthropathy
  • Defects of plantar support
  • Marked asymmetry and/or dysmetry of lower limbs

Extrinsic

  • Incorrect training
  • Unsuitable footwear
  • Unfavorable training conditions

Differential Diagnosis

Differential Diagnosis Adductor Tendinopathy

Differential Diagnosis Thigh Pain

Differential Diagnosis Groin Pain

Clinical Features

Point tenderness at the tendinous insertion
Demonstration of the Adductor Squeeze Test

History

  • Patient will complain of medial thigh or groin pain
  • There may have been an acute injury previously, but often insidious in nature
  • They may also endorse hip pain, stiffness

Physical Exam

  • Pain with passive abduction
  • There may be pinpoint tenderness, often at the tendinous insertion
  • They may have weak adduction
  • Passive stretch of the adductors may reproduce pain
    • Associated with higher MRI injury grade[8]

Special Tests

Evaluation

Small calcifications at the pubic symphysis suggesting adductor tendinopathy[9]
Ultrasound (a) and MRI investigation on the axial plane (b). Both images highlight a reduction of the phlogistic phenomenon (blue arrow). The cortical profile irregularity, however, remains.[10]
Proximal rupture of the adductor longus. Fat-suppressed coronal (a) and sagittal (b, c) T2-weighted images showing blood pooling (white arrows) and tendon retraction (star). Note the continuity of the common RA–AL aponeurosis (arrowheads) with the tendon of the rectus abdominis.[11]

Radiographs

MRI

  • Useful to distinguish adductor tendinopathy from other pathology
  • Gold standard for diagnosis provides:
    • High-resolution visualization of tendon pathology
    • Grading of injury severity
    • Assessment of associated bone marrow edema or enthesopathy
  • Findings[12]
    • Edema at the site of injury
    • Often at the attachment of the adductor longus to the body of the pubis
    • If enthesopathy, will show periostitis and adjacent marrow edema

Ultrasound

  • Can visualize majority of structures[13]
  • Identify area, extend of injury
  • Serial examinations during recovery phase
  • effective for detecting tendinopathy, partial tears, and avulsions,
  • Can be used for contralateral comparison

CT

  • Rarely indicated
  • Reserved for specific cases where detailed bone assessment is required

Classification

  • N/A

Management

Nonoperative

  • Cessation of all activity
    • Load management and gradual return to play are essential
  • NSAIDS
  • Physical Therapy[14]
    • Targeting core muscles
    • Eccentric exercises on adductor muscle group
    • Exercise therapy is superior to passive modalities (Stretching, electotherapy, massage), associated with higher return to play[15]
  • Stretching
  • Tendon recovery procedures
  • Unclear utility

Procedures

Operative

  • Indications
    • Failure of conservative measures
  • Technique
    • Adductor open tenotomy
    • Mini-invasive bilateral adductor tenotomy

Rehab and Return to Play

Exercises for adductor tendinopathy[17]

Rehabilitation

  • When patient is relatively pain free[18]
    • Begin progressive range of motion
    • Strengthening exercises
  • Acute phase
    • Postural balance techniques through global and site specific stretching
    • Mechanical and proprioceptive orthotic insoles
    • Global postural reeducation (RPG)
  • Subacute phase
    • Muscle strengthening is increased by the introduction of concentric and eccentric exercises
    • Cardiovascular reconditioning in the gym or in a therapeutic swimming pool
    • Core stability

Return to Play/Work

  • Aerobic running with increasing speed
  • Gradually short but intense anaerobic training
  • Stretching and repeated exercises
  • Gradually, exercises with sprints and jumps
  • Athletes begin to practice again with the ball
  • Finally one-on-one tackles and training matches

Prognosis and Complications

Prognosis

  • General
    • Generally favorable with appropriate management
  • Nonsurgical
    • High rates of return to play[19]
    • Return to play on average takes 9-14 weeks
  • Surgical[20]
    • Can result in substantial functional improvement
    • Not all patients return to pre-injury level of sport
    • Maffuli et al: 10% of athletes ceased sport after tenotomy, and 14% returned at a lower level

Complications

  • Chronic pain
  • Persistent functional limitation
  • Recurrence of symptoms
  • Surgical complications
    • Persistent weakness
    • Altered gait
    • Failure to return to previous activity levels
  • Tendon rupture (especially following corticosteroid injection)

See Also

References

  1. ↑ Renström, P. A. F. H., and L. Peterson. "Groin injuries in athletes." British Journal of Sports Medicine 14.1 (1980): 30.
  2. ↑ Akermark, Christian, and Christer Johansson. "Tenotomy of the adductor longus tendon in the treatment of chronic groin pain in athletes." The American journal of sports medicine 20.6 (1992): 640-643.
  3. ↑ Ekstrand J, Hilding J. The incidence and differential diagnosis of acute groin injuries in male soccer players. Scand J Med Sci Sports. 1999:98–103.
  4. ↑ Mosler, Andrea B., et al. "Epidemiology of time loss groin injuries in a men’s professional football league: a 2-year prospective study of 17 clubs and 606 players." British journal of sports medicine 52.5 (2018): 292-297.
  5. ↑ Image courtesy of teachmeanatomy.info
  6. ↑ Image courtesy of teachmeanatomy.info
  7. ↑ Bouvard M, Dorochenko P, Lanusse P, Duraffour H. La pubalgie du sportif, stratégie thérapeutique. J Traumatol Sport. 2004:146–163
  8. ↑ Serner, Andreas, et al. "Associations between clinical findings and MRI injury extent in male athletes with acute adductor injuries—A cross-sectional study." Journal of Science and Medicine in Sport 24.5 (2021): 454-462.
  9. ↑ Bancroft, Laura W., and Donna G. Blankenbaker. "Imaging of the tendons about the pelvis." American Journal of Roentgenology 195.3 (2010): 605-617.
  10. ↑ Thomas, Ewan, et al. "The Case of Insertional Adductor Tendinopathy of an International-Level 3,000-m Steeplechase Runner." Frontiers in Sports and Active Living 3 (2021): 688280.
  11. ↑ Pesquer, L., et al. "Imaging of adductor-related groin pain." Diagnostic and Interventional Imaging 96.9 (2015): 861-869.
  12. ↑ Pezzotta, G., et al. "MRI characteristics of adductor longus lesions in professional football players and prognostic factors for return to play." European Journal of Radiology 108 (2018): 52-58.
  13. ↑ Flores, Dyan V., et al. "US and MRI of pelvic tendon anatomy and pathologic conditions." Radiographics 42.5 (2022): 1433-1456.
  14. ↑ Irby, Alyssa, et al. "Clinical management of tendinopathy: a systematic review of systematic reviews evaluating the effectiveness of tendinopathy treatments." Scandinavian journal of medicine & science in sports 30.10 (2020): 1810-1826.
  15. ↑ Almeida, Matheus O., et al. "Conservative interventions for treating exercise‐related musculotendinous, ligamentous and osseous groin pain." Cochrane database of systematic reviews 6 (2013).
  16. ↑ Shomal Zadeh, Firoozeh, et al. "The effectiveness of percutaneous ultrasound-guided needle tenotomy compared to alternative treatments for chronic tendinopathy: a systematic review." Skeletal Radiology 52.5 (2023): 875-888.
  17. ↑ Grimaldi, Alison, and Angela Fearon. "Gluteal tendinopathy: integrating pathomechanics and clinical features in its management." journal of orthopaedic & sports physical therapy 45.11 (2015): 910-922.
  18. ↑ Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med. 2001;29:521–533
  19. ↑ Farrell, Steven Gonzales, Munif Hatem, and Srino Bharam. "Acute adductor muscle injury: a systematic review on diagnostic imaging, treatment, and prevention." The American Journal of Sports Medicine 51.13 (2023): 3591-3603.
  20. ↑ Maffulli, Nicola, et al. "Bilateral mini-invasive adductor tenotomy for the management of chronic unilateral adductor longus tendinopathy in athletes." The American Journal of Sports Medicine 40.8 (2012): 1880-1886.
Created by:
John Kiel on 11 June 2019 01:50:21
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Last edited:
23 September 2025 16:58:10
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